HomeMy WebLinkAbout02-1181PETITION FOR PROBATE and GRANT OF LETTERS
Estate of JUNE H. KAUFFMAN
also known as
Deceased.
No. ~/-~ - l/f~/
To: Register of Wills for the
County of Cumberland in the
Social Security No. 205-16-5546 Commonwealth of Pennsylvania
The pe;tition of the undersigned respectfully represents that:
Your petitioner is(are) 18 years of age or older and the Executrix named in the last will of the
above decedent, dated March 11, 2000, and codicil(s) dated [none].
Decedent was domiciled at death in Cumberland County, Pennsylvania, with her last family or
principal residence at Forest Park Health Center, 700 Walnut Bottom Road, Carlisle, South
Middleton Township.
Decedent, then 78 years of age, died December 24, 2002, at Forest Park Health Center,
Carlisle, Pennsylvania.
Except as follows, decedent did not marry, was not divorced and did not have a child born or
adopted after execution of the will offered for probate; was not the victim of a killing and was never
adjudicated incompetent:
Decedent at df;ath owned property with estimated values as follows:
(If domiciled in Pa.) All personal property $ unestimated
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled in Pa.) Personal property in County $
Value of real estate in Pennsylvania $
situated as follows: None
WHEREFORE, petitioner respectfully requests the probate of the last will and codicil(s) presented
herewith and the grant of letters testamentary thereon.
Debra K. Minnich
221 Hickory Lane
Shippensburg, PA 17257
(717)530-5940
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA )
. SS.
COUNTY OF CUMBERLAND )
The petitioner above-named swears or affirms that the statements in the foregoing petition are true
and correct to the best of the xno~~ledge and belief of petitioners and that as personal representatives of
the above decedent, petitioners will well and truly administer the estate according to law.
Sworn to or ai-firmed and subscribed
before me this t~dTN day of
~s~•
~.c1 ,~~~~~ Register
Debra K. Minnich
/ 7 /!02 - a-
No. ~ I - C~a. - //~J
Estate of JUNE H. KAUFFMAN, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW, Lem6eY tel. ~rx~a. , in consideration of the petition on the reverse side
hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated March 11, 2000, described therein be admitted to probate
and filed of record as the last will of June H. Kauffman and Letters Testamentary are hereby granted to
Debra K. Minnich.
Will Book #
Page
FEES
Probate, Letters, Etc.
Shor~Certificates( )
)~enunc tiai on
J ~.~P
TOTAL
Filed -~_G. ~ ~ , ~Q ~
~~,~n
Register of Wills
No V. Otto III, Esduire (27763)
$ '~O ~° ATTORNEi' (Sup. Ct. I.D. No.)
$ ~ MARTSON DEARDORFF WILLIAMS & OTTO
$ ~ ° ° 10 East High Street
$ lo. oo Carlisle, PA 17013
$_~Z. ~-,n (717) 243-3341
F:\FILES\DATAFILE\ESTATES\ 10472-2-petitioaletter
F \F[LES\DATAFILE\ESTATES\ 10472-2-oath.nonsubscnbing
Created: 02/09/99 04:54:34 PM
Revised. 12/30/02 OI :35:33 PM
REGISTER OF WILLS OF CUMBERLAND COUNTY
OATH OF NON-SUBSCRIBING WITNESS
Debra. K. Minnich and Bary E. Kauffman, (each) a subscriber hereto, (each) being duly
qualified according to law, depose(s) and say(s) that they are familiar with the signature of June H.
Kauffman, testatrix of the Will presented herewith and that they believe the signature on the Will
is in the handwriting of June H. Kauffman to the best of their knowledge and belief.
Sworn to or affirmed and subscribed ~~ CL~ ~_
before me this ~~k day of (Name)
~.1 ~~~h,L~Y ,~~. Debra K. Minnich
221 Hickory Lane
-~ ~7 % Shipp sburg, P 17257
~uLJ/~Z~/j~~ Register
(Name)
Barg E. Kauffman
25608 Wilde Avenue
Stevenson Ranch, CA 91380
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I, JUNE H. I~AUFFMAN, of 3~'! Garland Drive, Carlisle, Cumberland County,
Pennsylvania, being of sound mind and memory declare this to be my Last Will and Testament
and revoke any wiii or codicil previously made by me.
ITEM I: I direct that all my just debts and funeral expenses, including my gravemarker
and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable
after my decease as a part of the administration of my estate.
I T'ENI i1: I give, devise and bequeath ail of my estate of every nature and wheresoever
situate to my issue per stirpes living on the thirty-first (s i st j day following my death in shares of
equal value, share and share alike.
IfiElVI III: I appoint DEBT-tA K. l~iII~iNICFI Executrix of this, my Last Will and
~.u,,~~.,.~
ra, $.r~ ~f...s
~...fy ~nzn
Testament.
ITEM IV: I direct that my Executrix or her successor shall not be required to give bond
for the faithful performance of her duties in any jurisdiction.
(~r~) s.+s-.Qn~s
r~
-,
IN WITNESS WHEREOF, I hereunto set my hand and seal to this my Last -Will and
Testament, written on two (02) sheets of paper, dated this I ~ day of , .
E H. KAUFFMA
'The preceding instrument, consisting of this and one (O1) other typewritten page, each
identified by the signature of the Testatrix, JUNE H. KAUFN~MAN, was on the day and date
thereof signed, published and declared by JUNE H. KAUh~`~`'MAN, the Testatrix herein named,
as and fir her Last V1jill, in the presence of us, who, at her request, in her presence, and in the
presencE; of each other, have subscribed our names as witnesses hereto.
~~ ~
~~ I;`~ i ~- residin at i
~ I ~ ~ D ~~~~ ~ ~~
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residing at / l~^r~ ~ ~~-
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F: \FILES\DATAFI LE\ES TATES\ 10472-2-notice. cen
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: JUNE H. KAUFFMAN
Date of Death:
File No
To the Register:
December 24, 2002
2~-u
~-
I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court
Rules was served on or mailed to the following beneficiaries of the above-captioned estate on or
about January 6, 2002.
Debra. K. Minnich, 221 Hickory Lane, Shippensburg , PA 17013
Bary E. Kauffinan, 25608 Wilde Avenue, Stevenson Ranch, CA 91381
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: N/A
Date: Januar 6 2002 Si ature ~~• ~+~
.Y ~ ~
Name No V. Otto III, Esquire
MARTSON DEARDORFF WILLIAMS & OTTO
Ten East High Street
Carlisle, PA 17013
(717) 243-3341
Attorneys for Personal Representative
V
F: \FI LES\DATAFILE\E'.STATES\ 10472-2•notice.cert
CORRECTED CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: JUNE H. KAUFFMAN
Date of Death
File No
To the Register:
December 24, 2002
2
I certiify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court
Rules was served on or mailed to the following beneficiaries of the above-captioned estate on or
about January 6, 2003.
Debra K. Minnich, 221 Hickory Lane, Shippensburg , PA 17013
Bary E. Kauffman, 25608 Wilde Avenue, Stevenson Ranch, CA 91381
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: N/A
Date: January 6, 2003 Signature
Name
No V. Otto III, Esquire
MARTSON DEARDORFF WILLIAMS & OTTO
Ten East High Street
Carlisle, PA 17013
(717) 243-3341
Attorneys for Personal Representative
.REV.li!OC1U+I$.jJO)
*'
;-') - / /,:) - ,;:v
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
....-'
l.bi:. ':XL Y
FILE NUMBER
21 02 1181
COUNTY CODE YEAR NUMBER
SOCIAL SECURITY NUMBER
205-16-5546
12/24/2002
08/14/1924
THIS RETURN MUST BE FILi:D IN DUPLICATE WITH THE
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09.
1, Original Return
4 Limited Estate
Decedent Died Testate (Attach copy
of Will)
Litigation Proceeds Received
CQMMONWE/l.L Tl-\ OF PENNSY\.. VANIA
(JEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG,PA 17128.0601
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Q
W
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W
Q
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
KAUFFMAN, JUNE H.
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
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o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after
12-12-82)
o 7. Decedent Maintained a Living Trust (Attach
copy of Trusl)
o 10. Spousal Poverty Credit (date of death between
12-31-91 n 1-1-95
THIS SECTION MUST BECOMRLETEO: ALicORRESRONDENCE'AND CONFIDENTIAL.TAX INFORM TION'SHOuLD BE DIRECTED TO: "
AME COMPLETE MAILING ADDRESS
lvo V. OTTO III, Esquire
Ten East High Street
Carlisle, PA 17013
(1) None CFF,C:I/;L ONLY
(2) None
(3) None
(4) None
(5) 62,841.54
(6) None
(7) None
(8) 62,841.54
(9) 7,494.00
(10) 18,078.20
DATE OF DEATH (MM-DD-YEAR)
DATE OF BIRTH (MM-DD YEAR)
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
~
8
IRM NAME (If applicable)
Martson Deardorff W illiarns & Otto
ELEPHONE NUMBER
717/243-3341
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Crosely Held Corporation, Partnership or Sole.Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets {total Lines 1-7}
9. Funeral Expenses & Administrative Costs (Schedule H)
o 3. Remainder Return (date of death prior to 1.2-13-82)
o
o
5. Federal Estate Tax Re\um Required
8. Tolal Number of Safe Deposit Boxes
o 11.Election to tax under Sec. 9113{A) (Attach Sch 0)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
SEE tNSTRUCTIONS ON REVERSE SIDE FOR ARRLICABLE RATES
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
>>BE SURE TO ANSWER AL~'QUESTTONS ON !lEVlMSESToE AND RECHECK MATH <<'""
Form REV.1500 EX (Rev. 6-00)
Copyright 2000 form software only The Lackner Group, Inc.
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
(11)
25,572.20
(12)
37,269.34
(13)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
37,269.34
15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a)(1.2)
z 37,269.34 .045 (16)
0 16.Amount of line 14 taxable at fineal rate x
~
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~ 17.Amount of Line 14 taxable at sibling rate x .12 (17)
~
0
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~ 18. Amount of Line 14 taxable at collateral rate x .15 (18)
~
19. Tax Due (19)
1,677.12
1,677.12
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Decedent's Complete Address:
STREET ADDRESS
700 Walnut Bottom Road
CITY
I STATE PA
IzlP 17013
Carlisle
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2, CreditsfPayments
A. Spousal Poverty Credit
S. Prior Payments
C. Discount
83.86
Total Credits (A + B + C)
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (0 + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Une 5 + SA. This is the BALANCE DUE.
Make Check
to: REGISTER OF
AGENT
(1)
1,677.12
(2)
83.86
(3) 0.00
(4)
(5) 1,593.26
(5A)
(58) 1,593.26
1. Did decedent make a transfer and:
a. retain the use Of income of the property transferred;........... ........................
b. retain the right to designate who shall use the property transferred or its income;.
c. retain a reversionary interest; or...... .. ......................" ...................... .....................
d. receive the promise for life of either payments, benefits or care?....>> .............,..........................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?............. ....................... ...................... .................................
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes No
~ I
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?..
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?......................... ................. ............................,......
o 181
D 181
D 181
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
preparer other than the persoo81 representative is based on aU information of which preparer has any knowledge
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
Debra K. Minnich
~~Ln,^ J..(,m~/U.u.'h-
SIGNATU 0 PERSON ~ESPO SIBl: ~OR FILING RETURN
221 Hickory Lane
Shippensburg, P A 17257
DATE
3//7ID5
JDAT '
ADDRESS
ADDRESS
SIGNATURE
Ivo V. OTT
Ten East High Street
Carlisle, PA 17013
!.'-
DATE
3/;2/ /~3
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3%. [72 P.S. s.9116 (a) (1.1) (i)).
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 00/0
[72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax return are stiJJ applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. ~9116 (a) (1.2)J.
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116
1.2) [72 P.S. !l9116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% 172 P.S. 99116 (a) (1.3)]. A sibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
'*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
KAUFFMAN, JUNE H.
I FILE NUMBER
21-02-1181
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM
NUMBER
1
DESCRIPTION
VALUE AT DATE OF
DEATH
13,793.46
M&T Bank, checking account #2676032119
2
M&T Bank, savings account #15004198282706
40,065.08
3
Veterans Administration, death pension covering periods 11/1/01-12/1/02
8,800.00
4
2002 P A Income Tax refund
183.00
TOTAL (Also enter on Line 5, Recapitulation)
62,841.54
*'
SCHEDULE H
FUNERAL EXPENSES &
ADMINIS1RATJVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
KAUFFMAN, JUNE H.
I FILE NUMBER
21 - 02 - 1181
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
1 [prepaid]
B. ADMINISTRATIVE COSTS: 3,142.00
1. Personal Representative's Commissions
Debra K. Minnich
Social Security Number(s)! EIN Number of Personal Representative(s):
Street Address 221 Hickory Lane
City Shippensburg State PA Zip 17257
-
Year(s) Commission paid 2003
2. Attorney's Fees Martson Deardorff Williams & Otto (estimated) 3,900.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 92.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Register of Wills, additional probate fee 45.00
2 Register of Wills, filing fee, Inheritance Tax Return 15.00
Total of Continuation Schedule(s) 300.00
TOTAL (Also enter on line 9, Recapitulation) 7,494.00
'*
Schedule H
FW1ElIaI Expenses &
Adninistrative Costs continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENl
ESTATE OF
KAUFFMAN, JUNE H.
I FILE NUMBER
21 - 02 - 1181
3
Reserved for additional filing fees and miscellaneous expenses
300.00
Page 2 of Schedule H
*'
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETUFlN
RESIDENT DECEDENT
ESTATE OF
KAUFFMAN, JUNE H.
I FILE NUMBER
21 - 02 - 1181
Include unreimbursed medical expenses.
ITEM
NUMBER
1 Department of Public Welfare claim
DESCRIPTION
AMOUNT
17,322.07
2
Forest Park Nursing Home, account payable
686.13
3
Group, preparation of 2002 individual income tax return
70.00
TOTAL (Also enter on Line 10, Recapitulation)
18,078.20
REV.1513 EX. (9-00)
*'
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
KAUFFMAN, JUNE H.
I FILE NUMBER
21 - 02 - 1181
RELATIONSHIP TO AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY DECEDENT OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1 Debra K. Minnich Daughter 1/2 estate residue
221 Hickory Lane
Shippensburg, P A 17257
2 \ Bary E. Kauffman Son 1/2 estate residue
25608 Wilde AVenue
Stevenson Ranch, CA 91381
I
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
I
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART" - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV.1500 COVER SHEET
~ M&rBank
Manufacturers and Traders Trust Company, 1100 Wer,rle Driv8 P,O, Box 767 Buffalo, NY 14240-0767
January ]4, 2003
RE:
Estate Search
The Estate of:
Date of Death (D.O.D.)
To Whom It May Concern:
JUNE H KAUFFMAN
12/24/2002
Identified below is the account information requested.
1. IVI&T Bank accounts in which the decedent's name appears:
Account
Type
Account Number
CHK
2676032119
OPENED 7/89
SAY
15004]98282706
OPENED 1110]
Account Title
Opening Branch
D.O.D. Accrued Interest
Balances
(Includes ACCL
Int.)
$13,793.46 $.00
JUNE H KAUFFMAN
BARRY KAUFFMAN POA
DEBRA MINNICH POA
JUNE H KAUFFMAN
4345
4345
$40,056.91 $8.] 7
Account Number
2. Loansl Mortgages, or other obligations titled in the decedent's name
Account Description
Amount Owed
NO Safe Deposit Box titled in the Decedent's name existed at our office.
If you have any questions about the information provided, please contact our Records Department at (716) 635-4010 or 1-800-724-
2440 outside of the Buffalo, NY calling area. Thank you.
Sincerely,
M&T BANK CORPORATION
BY:
~'
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Authonzed Signature
DATE:
I '{ ,2
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seH "E"I~ 1~2...
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
ESTATE RECOVERY PROGRAM
PO BOX 8466
HARRISBURG, PA 17105-8486
January 14, 2003
MDW&O LAW OFFICES
CORRINE L MYERS
10 EAST HIGH STREET
CARLISLE PA 17013
Re: JUNE KAUFFMAN
CIS #: 330153932
SSN: 205-16-5546
Date of Death: 12/24/2002
Dear Mrs. Myers:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $~7,322.0? against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense, namely $.00, was incurred during the
last six months of the decedent's life; therefore;-it is a Class 3 claim
pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20
Pa. C.S.A. 3392(3). The balance of the claim, namely $17.322.07, is to be
entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. Lf the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
'Y;l:~ ~
Sandi L. Sral
TPL Program Investigator
717-772-6238
717-772-6553 FAX
Enclosure
SCH
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.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION - CASUAL TV UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
Janua/y 14, 2003
STATEMENT OF CLAIM SUMMARY
Estate of KAUFFMAN, JUNE
330 153 932
INPATIENT
OUTPATIENT
LONG TERM CARE
DRUG
.00
.00
.00
16,586.44
735.63
.00
.00
16,586.44
735.63
.00
.00
.00
.00
17,322.07
17 ,322.07
COt-lMONWBALTH OF PENNSYLVANIA
DEPARTMENT OF PUBUG WELFARE
EIN - 23-6003113
c
COMMONWEALTH OF PENNSYLVANiA
DEPARTMENT OF PUBLIC WELFARE
January 14, 2003
STATEMENT OF CLAIM
N.AtJfE
ID
KAUFFMAN, JUNE
330 153 932
CONTINUING CARE RX
28 S 2ND STREET
NEWPORT PA 17074
08/09/01 - 08109/01 11/12/01 128971799501 000000000000 69.24 18.34
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
08109/01 - 08109/01 11/12/01 128971907701 000000000000 79.27 20.80
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
08109/01 . 08/09/01 11/12/01 128971904301 000000000000 8.31 2.07
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
08109/01 - 08/09/01 11/12/01 128971799901 000000000000 125.09 32.00
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
09/08/01 . 09/08101 11112/01 128971921601 000000000000 125.09 32.00
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
09/08/01 . 09/08/01 11/12/01 128971769501 000000000000 8.31 2.07
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
09/08101 . 09/08/01 11/12/01 128971899301 000000000000 79.27 20.80
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
09/08/01 . 09/08/01 11/12/01 128971886301 000000000000 69.24 18.34
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
January 14,2003
STATEMENT OF CLAIM
NAME KAUFFMAN,JUNE
10 330 153 932
CONTINUING CARE RX
28 S 2ND STREET
NEWPORT PA 17074
10/08/01 - 10/08101 11/12/01 128971869801 000000000000 8.29 2.19
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/08101 - 10/08/01 11/12/01 128971990701 000000000000 79.27 20.80
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/08101 - 10/08101 11/12/01 128971914401 000000000000 125.09 32.00
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/08101 - 10108101 11112/01 128971940301 000000000000 69.24 18.34
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/26/01 - 10/26101 11119101 129971632001 000000000000 12.03 2.57
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/29/01 - 10/29/01 11/26/01 130470223701 000000000000 61.09 15.06
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/29/01 - 10/29/01 11/26/01 130273833601 000000000000 69.25 16.86
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11/07/01 . 11/07/01 12/03/01 131270194301 000000000000 75.99 18.34
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OFPENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
January 14, 2003
STATEMENT OF CLAIM
NAME KAUFFMAN, JUNE
10 330 153 932
CONTINUING CARE RX
28 S 2ND STREET
NEWPORT PA 17074
11/07/01 " 11/07/01 12/03/01 131270194101 000000000000 138.04 32.00
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11/07/01 - 11/07/01 12/03/01 131270194201 000000000000 8.29 2.19
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11/07/01 - 11/07/01 12/03101 131270194001 000000000000 87.13 20.80
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12/07101 - 12/07/01 01/07/02 134570421901 000000000000 75.99 18.34
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12/07/01 - 12/07101 01107102 134570421801 000000000000 138.04 32.00
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12/07/01 - 12/07/01 01/07/02 134570421701 000000000000 87.13 20.80
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12/07/01 - 12/07/01 01/07/02 134570421601 000000000000 8.29 2.19
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
01/06/02 - 01/06/02 02/04/02 200972742201 000000000000 8.29 5.32
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
January 14, 2003
STATEMENT OF CLAIM
NAME
10
KAUFFMAN, JUNE
330 153 932
CONTINUING CARE RX
28 S 2ND STREET
NEWPORT PA 17074
01/06/02 - 01/06/02 02104/02 200973184501 000000000000 87.13 79.26
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
01/06102 - 01/06/02 02111/02 201170371201 000000000000 75.99 69.24
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
01/06102 - 01106102 02104/02 200913182701 000000000000 125.09 125.08
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
01/24/02 - 01/24/02 02118/02 202470602001 000000000000 66.44 55.83
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
CONTINUING CARE RX 1,969.92 735.63
19 1622195
COMMONWEALTH OI'PENN$YLVANIA
DEPARTMENT OF PUBLIC WELFARE
January 14, 2003
STATEMENT OF CLAIM
NAME KAUFFMAN, JUNE
10 330153932
FOREST PARK HEALTH CENTER
1217 SLATE HILL RD
CAMP HILL PA 17011
07/30101 - 07/31101 11109102 231311283101 130693679501 257.14 257.14
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
08/01101 . 08131/01 11/09/02 231311283001 130693679401 2,726.22 2,726.22
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
09101101 . 09130/01 11/09/02 231311282901 130693679301 2,597.65 2,597.65
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
10/01101 . 10131101 11/09102 231311283201 131887155101 2,795.04 2,795.04
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
11/01/01 " 11/30/01 11109/02 231311283301 134797860101 2,664.25 2,664.25
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
12/01/01 " 12/31/01 01/21/02 201488903901 000000000000 2,795.04 2,795.04
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
01/01/02 - 01/31/02 11/09/02 231311283401 205088660001 2,751.10 2,751.10
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
PROViOE'RSUB TOTAL FOREST PARK HEALTH CENTER 16,586.44 16,586.44
36 1690613
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I, JUNE H. KAUFFMAN, of3tt Garland Drive, Carlisle, Cumberland County,
Pennsylvania, being of sound mind and memory declare this to be my Last Will and Testament
and revoke any will or codicil previously made by me.
ITEM I: I direct that all my just debts and funeral expenses, including my gravemarker
and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable
. after my decease as a part of the administration of my estate.
ITEM ll: I give, devise and bequeath all of my estate of every nature and wheresoever
situate to my issue per stirpes living on the thirty-first (31st) day following my death in shares of
equal value, share and share alike.
ITEM m: I appoint DEBRA K. MINNICH Executrix of this, my Last Will and
Testament.
ITEM IV: I direct that my Executrix or her successor shall not be required to give bond
for the faithful performance of her duties in any jurisdiction.
II
IN WITNESS WHEREOF, I hereunto set my hand and seal to this my Last Will and
Y1. . :2.atrO
Testament, written on two (02) sheets of paper, dated this ~ day of > rVJ..rr.f,~ , ~,
~ If 1< ~C~SEAL)
E H. KAUFFMA
The preceding instrument, consisting of this and one (01) other typewritten page, each
identified by the signature of the Testatrix, JUNE H. KAUF1<'MAN, was on the day and date
thereof signed, published and declared by JUNE H. KAUFFMAN, the Testatrix herein named,
as and for her Last Will, in the presence of us, who, at her request, in her presence, and in the
presence of each other, have subscribed our names as witnesses hereto,
I
12 k+l' reOO;'g.
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2
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 1 7 1 28-0601
RECEIVED FROM:
REV-1162 EX111-96)
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
N0. CD 002326
OTTO IVO VICTOR III ESQUIRE
10 E HIGH STREET
CARLISLE, PA 17013
fold
ESTATE INFORMATION: ssN: 2o5-is-5546
FILE NUMBER: 2102-1 181
DECEDENT NAME: KAUFFMAN JUNE H
DATE OF PAYMENT: 03/21 /2003
POSTMARK DATE: OO/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 1 2/24/2002
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
101 ~ $1,593.26
TOTAL AMOUNT PAID:
REMARKS: IVO V OTTO III ESQUIRE
CHECK# 96
INITIALS: AC
SEAL RECEIVED BY:
S 1, 593.26
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
~` '
J
~~
REGISTER OF WILLS OF CUMBERLAND COUNTY
STATUS REPORT UNDER RULE 6.12 _
(For Resident Decedents Dying After July 1, 1992),-j ~
~~~
Name of Decedent: JUNE H. KAUFFMAN ~_
r-
F_,;
Date of Death: December 24, 2002 ~
File No.: 2002-01181
Social Security lJo.: 205-16-5546
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect
to completion of'the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes x No
2. If the answer is No, state when the personal representative reasonably believes that the
administration Vvill be complete:
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes No x
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
c. Did the personal representative state an account informally to the parties in
interest?
Yes x No
d. Copies of receipts, releases, joinders and approvals offormal or informal accounts
may be filed with the Clerk of the Orphans' Court and may be attached to this report.
[Copies of Releases attached]
Date: July 3, :2003 Signature: ~u v ~ ~-
Name:
Address:
F: \FILES\DATAFILE\E STATES\ 10472-2. srep
No V. Otto III, Esquire
MARTSON DEARDORFF WILLIAMS & OTTO
Ten East High Street
Carlisle, PA 17013
(717) 243-3341
Counsel for personal representative
ESTATE OF JUNE H. KAUFFMAN
FILE NO. 21-02-1181 '~
__._ ~.. ,-..~. . ~,-.~ TiTTTTAITITATl~ nr-~~~L'T~TRT~TT i ~.~;f;'):'1~~
KNOW ALL MEN BY THESE PRESENTS that I, BABY E. ,~~~one of the
residuary legatees under the Last Will and Testament of JUNE H. I{AUFFMAN, late of Carlisle,
Cumberland County, Pennsylvania, deceased, do hereby acknowledge that upon execution of this
instrument, I received from DEBRA K. MINNICH, Executrix under the Last Will and Testament
of the said JUNE H. KAUFFMAN, my one-half share of estate residue in the following manner:
4/15/03 Cash $16,672.13
Cash 2,201.78
for a total distribution of Eighteen Thousand Eight Hundred Seventy-three and 91/100 ($18,873.91)
in full satisfaction of my residuary legacy under the terms of said Last Will and Testament.
AND, THEREFORE, I, the said BABY E. KAUFFMAN, do by these presents remise,
release, quit-claim, and forever discharge the said DEBRA K. MINNICH, Executrix aforesaid, her
heirs, executors and administrators, of and from the aforesaid partial distribution of my legacy, and
of and from all actions, suits, payments, accounts, reckonings, claims and demands whatsoever, from
the beginning of the world to the day of the date of these presents.
AND, THEREFORE, I, the said BARY E. KAUFFMAN, agree to refund to the Executrix
aforesaid, any portion of the distribution to which I am not properly entitled, and to the extent of said
distribution, to indemnify said Executrix for claims made against her as Executrix, and to reimburse
to said Executrix all expenses and costs incurred in connection with any such claims. ~
~~~~,'
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ,~~ day of
f
v.\~\
-__- ~~. a~ ~ -
D
~~ , ; ~ ~ j ` t , Bary,~E. Kauffin n ,s
f .F ~ ~
i ~; •:,
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F:\FILESIDATAFILE\ESTATES\10471:-2.finaLrelease
ESTATE OF JUNE H. KAUFFMAN
FILE NO. 21-02-1181
RECEIPT RELEASE AND REFUNDING AGREEMENT
KNOW ALL MEN BY THESE PRESENTS that I, DEBRA K. MINNICH, one of the
residuary legatees under the Last Will and Testament of JUNE H. KAi.TFFMAN, late of Carlisle ,
Cumberland County, Pennsylvania, deceased, do hereby acknowledge that upon execution of this
instrument, I received from DEBRA K. MINNICH, Executrix under the Last Will and Testament
of the said JUNE H. KAUFFMAN, my one-half share of estate residue in the following manner:
4/15/03 Cash $16,672.14
5/23/03 Cash 2,201.77
for a total distribution of Eighteen Thousand Eight Hundred Seventy-three and 91/100 ($18,873.91)
in full satisfaction of my residuary legacy under the terms of said Last Will and Testament.
AND, THEREFORE, I, the said DEBRA K. MINNICH, do by these presents remise, release,
quit-claim, and forever discharge the said DEBRA K. MINNICH, Executrix aforesaid, her heirs,
executors and administrators, ofand from the aforesaid partial distribution of my legacy, and of and
from all actions., suits, payments, accounts, reckonings, claims and demands whatsoever, from the
beginning of the world to the day of the date of these presents.
AND, T HEREFORE, I, the said DEBRA K. MINNICH, agree to refund to the Executrix
aforesaid, any portion of the distribution to which I am not properly entitled, and to the extent of said
distribution, to indemnify said Executrix for claims made against her as Executrix, and to reimburse
to said Executrix all expenses and costs incurred in connection with any such claims.
TN WITNESS WHEREOF, I have hereunto set my hand and seal this 13~`' day of
..CLL.,-,.ems , ? 003 .
Witness:
~~. ,o ~,-~ I .
ebra K. Minnich